For patients with aortic stenosis, transcatheter aortic valve replacement (TAVR) offers a less invasive treatment modality than conventional surgical valve replacement. Although the surgery is ...performed traditionally under general anesthesia (GA), recent studies have described success with TAVR using local anesthesia (LA) and/or conscious sedation. The study authors performed a pairwise meta-analysis to compare the clinical outcomes of TAVR based on operative anesthesia management.
A random effects pairwise meta-analysis via the Mantel-Haenszel method.
Not applicable, as this is a meta-analysis.
No individual patient data were used.
Not applicable, as this is a meta-analysis.
The authors comprehensively searched the PubMed, Embase, and Cochrane databases to identify studies comparing TAVR performed using LA or GA. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% CIs. The authors’ pooled analysis included 14,388 patients from 40 studies (7,754 LA; 6,634 GA). Compared to GA TAVR, LA TAVR was associated with significantly lower rates of 30-day mortality (RR 0.69; p < 0.01) and stroke (RR 0.78; p = 0.02). Additionally, LA TAVR patients had lower rates of 30-day major and/or life-threatening bleeding (RR 0.64; p = 0.01), 30-day major vascular complications (RR 0.76; p = 0.02), and long-term mortality (RR 0.75; p = 0.009). No significant difference was seen between the 2 groups for a 30-day paravalvular leak (RR 0.88, p = 0.12).
Transcatheter aortic valve replacement performed using LA is associated with lower rates of adverse clinical outcomes, including 30-day mortality and stroke. No difference was seen between the 2 groups for a 30-day paravalvular leak. These results support the use of minimally invasive forms of TAVR without GA.
Unicompartmental knee arthroplasty (UKA) offers a less invasive alternative to total knee arthroplasty (TKA), but is accompanied by a high revision risk. The aim of our study was to perform a ...meta-analysis comparing outcomes of UKA revised to TKA versus primary TKA, to assess if UKA is an effective treatment option, despite its potential need for revision.
Studies comparing matched cohorts of patients with UKA revised to TKA versus primary TKA were identified via the PubMed, Ovid EMBASE, and Scopus databases. The following outcome measures were compared between treatment modalities: postoperative reoperation or revision, total complications, range of motion, patient-reported outcome measures, and length of stay.
Ten studies were included with 1,070 patients: 410 UKA to TKA and 660 primary TKA. At an average follow-up of 5.6 years in the UKA to TKA cohort and 5.7 years in the primary TKA cohort, there were no significant difference in risk of revision (p = 0.81), total complications (p = 0.54), range of motion (p = 0.09), or length of stay (p = 0.31). Both objective and functional Knee Society Score were significantly higher in patients with primary TKA (p < 0.01). However, there was no difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or pain scores (p = 0.13 and p = 0.21, respectively).
UKA revised to TKA produced comparable clinical and patient-reported outcomes to a primary TKA. UKA may be an effective treatment option in unicompartmental arthritis that would allow for improved functionality and satisfaction without the concern of outcomes deteriorating in patients where a revision becomes necessary.
Background
The ideal conduit for mitral valve replacement (MVR) remains elusive, particularly among younger patients due to increased life expectancy. We perform a pairwise meta-analysis comparing ...the use of bioprosthetic valves (BPV) and mechanical mitral valves (MMV) in patients < 70 years old undergoing MVR.
Methods
We comprehensively searched medical databases to identify studies comparing the use of BPV and MMV in patients < 70 years old undergoing MVR. Pairwise meta-analysis was performed using the Mantel–Haenszel method in R version 4.0.2. Outcomes were pooled using the random effect model as risk ratios (RR) with their 95% confidence intervals (95% CI).
Results
16,879 patients from 15 studies were pooled. Compared to MMV, BPV was associated with significantly higher rates of 30-day mortality (RR 1.53,
p
= 0.0006) but no difference in 30-day stroke (RR 0.70,
p
= 0.43). At a weighted mean follow-up duration of 14.1 years, BPV was associated with higher rates of long-term mortality (RR 1.28,
p
= 0.0054). No difference was seen between the two groups for risk of long-term stroke (RR 0.92,
p
= 0.67), reoperation(RR 1.72,
p
= 0.12), or major-bleeding (RR 0.57,
p
= 0.10) at a weighted mean follow-up duration of 11.7, 11.3, and 11.9 years, respectively.
Conclusion
The use of MMV in patients < 70 undergoing MVR is associated with lower rates of 30-day/long-term mortality compared to BPV. No significant differences were observed for risk of 30-day/long-term stroke, long-term reoperation, and long-term major bleeding. These findings support the use of MMV in younger patients, although prospective, randomized trials are still needed.
Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful ...minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.
A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.
A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.
MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.
Background
There has been a resurgence in interest regarding the Ross procedure due to recent publications detailing positive long-term outcomes. Conversely, surgical aortic valve replacement (SAVR) ...with a pulmonary homograft (PH), mechanical (MV), bioprosthetic (BV), or the Ozaki procedure each has its own technical advantages and disadvantages. Therefore, we performed a network meta-analysis (NMA) comparing other alternatives to Ross procedure.
Methods
Medical databases were comprehensively searched for studies comparing the Ross procedure with AVR using a PH, MV, BV, or the Ozaki procedure. Outcomes were pooled as risk ratios (RR) with their 95% confidence intervals (95% CI).
Results
A total of 7816 patients were pooled for our NMA from 24 studies. Compared to Ross procedure, both BV and MV were associated with significantly higher rates of 30-day mortality of RR (2.37, 95% CI 1.20–4.67) and (1.88 95% CI 1.04–3.40), respectively, with no significant difference regarding PH or Ozaki. However, only MV was associated with a higher risk of 30-day stroke (RR 8.42, 95% CI 1.57–45.23) with no significant difference in the other alternatives, as well as 30-day MI which showed no significant differences between any of the aortic conduits compared to the Ross procedure. Regarding 30-day major bleeding, MV was associated with a higher when compared to the Ross procedure RR (4.58, 95% CI 1.94–10.85), PH was associated with a lower risk of major bleeding with RR (0.35, 95% CI 0.17–0.71), and BV showed no significant difference. With a mean follow-up duration of 8.5 years compared to the Ross procedure, BV, PH, and MV were associated with a higher risk of long-term mortality with RR (1.89, 95% CI 1.38–2.58), (1.38, 95% CI 1.0–1.87), and (1.94, 95% CI 1.52–2.47), respectively, with the Ozaki procedure showed no significant difference. Regarding long-term stroke—with a mean of 6.3-year follow-up duration—there were no significant differences between any of the aortic conduits compared to the Ross procedure. Nevertheless, long-term need for reintervention—with a mean follow-up duration of 17.5 years—was significant of higher risk with both BV and PH with RR (3.28, 95% CI 1.21–8.84) and (2.42, 95% CI 1.05–5.58), respectively, compared to Ross procedure with MV and Ozaki having no significant difference.
Conclusions
The Ross procedure is a viable treatment option for patients undergoing SAVR, showing promising outcomes at short- and long-term follow-ups.
Editorial board member reviewing 2 or more cardiothoracic journals 349 (21.7) Open Payment profile status of editorial board members (n = 1,611) Nonphysician editorial board member without Open ...Payment profile 37 (2.3) Editorial board members with Open Payments profiles receiving industry payments between 2018 and 2020 (n = 516) Editorial board members receiving general payments, industry research funding, or ownership/investment interest 458 (88.8) 8,420.53 1,075.86–56,548.00a,b Editorial board members receiving general payments 452 (87.6) 38,91.37 444.98–17,597.39 Classification of general payment Compensation for services other than consultingc 112 (21.7) Editorial board members receiving industry research funding 164 (31.8) 44,956.00 8,996.89–174,132.29 Editorial board members with ownership/investment interest 7 (1.4) 409,055.52 81,213.70–700,231.02 IQR interquartile range, US United States. aThere was no significant difference in the amount of industry payments received by editorial board members of free, open-access journals versus paid, subscription journals, P = 0.053. bThere was no significant association between the amount of industry payments received by editorial board members and journal impact factor, P = 0.104. cIncludes compensation for non-consulting services (e.g., faculty/speaker at an event other than a continuing education program) and compensation for serving as faculty or as a speaker for a medical education program Overall, 516 (32.0%) EBM had Open Payments profiles.
Background
Despite their extensive clinical use, opioids are characterized by several side effects. These complications, coupled with the ongoing opioid epidemic, have favored the rise of ...opioid-free-anesthesia (OFA). Herein, we perform the first pairwise meta-analysis of clinical outcomes for OFA vs opioid-based anesthesia (OBA) in patients undergoing cardiovascular and thoracic surgery.
Methods
We comprehensively searched medical databases to identify studies comparing OFA and OBA in patients undergoing cardiovascular or thoracic surgery. Pairwise meta-analysis was performed using the Mantel–Haenszel method. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% confidence intervals (95% CI).
Results
Our pooled analysis included 919 patients (8 studies), of whom 488 underwent surgery with OBA and 431 with OFA. Among cardiovascular surgery patients, compared to OBA, OFA was associated with significantly reduced post-operative nausea and vomiting (RR, 0.57; P = .042), inotrope need (RR .84, P = .045), and non-invasive ventilation (RR, .54; P = .028). However, no differences were observed for 24hr pain score (SMD, −.35; P = .510) or 48hr morphine equivalent consumption (SMD, −1.09; P = .139). Among thoracic surgery patients, there was no difference between OFA and OBA for any of the explored outcomes, including post-operative nausea and vomiting (RR, 0.41; P = .025).
Conclusion
Through the first pooled analysis of OBA vs OFA in a cardiothoracic-exclusive cohort, we found no significant difference in any of the pooled outcomes for thoracic surgery patients. Although limited to 2 cardiovascular surgery studies, OFA was associated with significantly reduced postoperative nausea and vomiting, inotrope need, and non-invasive ventilation in these patients. With growing use of OFA in invasive operations, further studies are needed to assess their efficacy and safety in cardiothoracic patients.
Objective:
Transcatheter aortic valve replacement (TAVR) has arisen as a viable alternative to surgery. Similarly, minimally invasive surgical aortic valve replacement (mini-SAVR), such as ...ministernotomy and minithoracotomy, have also gained interest. We conducted a pairwise meta-analysis to further investigate the efficacy of TAVR versus mini-SAVR.
Methods:
Medical databases were comprehensively searched for studies comparing TAVR with a mini-SAVR modality, defined as minimally invasive aortic surgery, ministernotomy, minithoracotomy, or rapid-deployment or sutureless SAVR. Random-effects meta-analysis was conducted using the generic inverse variance method. Primary outcomes included 30-day mortality, midterm mortality, 30-day stroke, acute kidney injury (AKI), paravalvular leak (PVL), new permanent pacemaker (PPM), new-onset atrial fibrillation, and postintervention mean and peak valve pressure gradients and were pooled as risk ratio (RR), mean difference (MD), or hazard ratio (HR) with 95% confidence interval (CI).
Results:
A total of 5,071 patients (2,505 mini-SAVR vs 2,566 TAVR) from 12 studies were pooled. Compared with TAVR, mini-SAVR showed significantly lower rates of both 30-day (RR = 0.63, 95% CI: 0.42 to 0.96, P = 0.03) and midterm mortality at 4 years of follow-up (HR = 0.76, 95% CI: 0.67 to 0.87, P < 0.001). Furthermore, mini-SAVR was protective against 30-day PVL (RR = 0.07, 95% CI: 0.04 to 0.13, P < 0.001) and new PPM (RR = 0.25, 95% CI: 0.11 to 0.57, P < 0.001). Conversely, TAVR was protective against 30-day AKI (RR = 1.67, 95% CI: 1.20 to 2.32, P = 0.002) and postinterventional mean gradients (MD = 1.65, 95% CI: 0.25 to 3.05, P = 0.02). No difference was observed for 30-day stroke (RR = 0.84, 95% CI: 0.56 to 1.24, P = 0.38), new-onset atrial fibrillation (RR = 1.79, 95% CI: 0.93 to 3.44, P = 0.08), or postinterventional peak gradients (MD = 3.24, 95% CI: −1.10 to 7.59, P = 0.14).
Conclusions:
Compared with TAVR, mini-SAVR was protective against 30-day and midterm mortality, 30-day PVL, and new permanent pacemaker, while TAVR patients had lower 30-day AKI. Future randomized trials comparing the efficacy of mini-SAVR approaches with TAVR are needed.
Visual abstract
Background
The ideal conduit for repair of the right ventricular outflow tract (RVOT) during the Ross procedure remains unclear and has yet to be fully elucidated. We perform a pairwise meta-analysis ...to compare the short-term and long-term outcomes of decellularized versus cryopreserved pulmonary allografts for RVOT reconstruction during the Ross procedure.
Main body
After a comprehensive literature search, studies comparing decellularized and cryopreserved allografts for patients undergoing RVOT reconstruction during the Ross procedure were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were early mortality and follow-up allograft dysfunction. Secondary outcomes were reintervention rates and follow-up endocarditis. A total of 4 studies including 1687 patients undergoing RVOT reconstruction during the Ross procedure were included. A total of 812 patients received a decellularized pulmonary allograft, while 875 received a cryopreserved pulmonary allograft. Compared to cryopreserved allografts, the decellularized group showed similar rates of early mortality (odds ratio, 0.55, 95% confidence interval, 0.21–1.41,
P
= 0.22). At a mean follow-up period of 5.89 years, no significant difference was observed between the two groups for follow-up allograft dysfunction (hazard ratio, 0.65, 95% confidence interval, 0.20–2.14,
P
= 0.48). Similarly, no difference was seen in reintervention rates (hazard ratio, 0.54, 95% confidence interval, 0.09–3.12,
P
= 0.49) nor endocarditis (hazard ratio, 0.30, 95% confidence interval, 0.07–1.35,
P
= 0.12) at a mean follow-up of 4.85 and 5.75 years, respectively.
Conclusions
Decellularized and cryopreserved pulmonary allografts are associated with similar postoperative outcomes for RVOT reconstruction during the Ross procedure. Larger propensity-matched and randomized control trials are necessary to elucidate the efficacy of decellularized allografts compared to cryopreserved allografts in the setting of the Ross.
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